Health Quiz

Are you pregnant? Please fill out the Notice of Pregnancy form instead.

Enter the required information to help us securely confirm your identity.

* Required Field

Last Name*

Medicaid ID*

Date of Birth*

Zip Code*

Below are questions about you and your family members who have Sunshine Health Medicaid. Please only answer for family members that have Sunshine Health.

Member Completing HRA:

Member Name:

Part 1: General Health and Utilization

Congratulations! Please fill out the Notice of Pregnancy form instead.

Can you tell me more?

When was the last time you saw your doctor?

How many?

5. Do you or family members have health problems that last a long time, like high sugar, breathing problems or heart trouble? Check all that apply.

Kidney problems or on dialysis, like Chronic Kidney Disease or End Stage Renal Disease

Heart problems, like high blood pressure (Hypertension), or any other heart problems (Myocardial Infarction, High Cholesterol, a fib or other heart rhythm issues, cardiovascular disease)

Blood sugar problems either low or high, Diabetes Type I or II

Breathing problems or use an inhaler or oxygen, Chronic Obstructive Pulmonary Disease (COPD), Asthma

Bone Issues or have you broken a bone in that past 12 months, Osteoporosis

Cancer or blood disorder where you have or had treatment or ended up in the hospital, Undergoing chemo or have history of chemotherapy, Sickle Cell Disorder, HIV/AIDS

Mental health issues/concerns (Feeling sad/down (Depression), Bipolar Disorder, ADHD (child) having issues with behaviors in school, Anxiety, Trouble with memory (Dementia), Trouble with trying to quit smoking, drinking, or taking recreational drugs)

Are you/they getting help for these feelings?

If yes to tobacco, how often?

If yes to alcohol, how often?

If yes to drugs, how often have you or anyone in your family used any prescription medications for non-medical reasons?

How often have you used any illegal drugs (this could include marijuana, cocaine or crack, heroin, methamphetamine (crystal meth), hallucinogens, ecstasy/MDMA)?

How many times did you/they visit or stay in the past 6 months?

What was the reason for these visits or stays?

What do you need help with?

Part 2: Pathway to Prosperity Screening

What problems are you facing with housing and/or food?

What is the barrier from having that insurance?

What kind of learning or job help are you looking for?

What kind of help do you need?

Did you know we have Sunshine Health Connects, a community resource database where you can find help? Visit CommunityResources.SunshineHealth.com to search by zip code.

Part 3: Closing

14. Is there anything else you want to tell us about you or your family or any other help you need? Like the need for job resources, economic self-sufficiency, independent services and health-related social needs, housing assistance, food sustainability.